Consultation Request Form with Dr. Moiz Hussain

Full Name

First NameLast Name

Contact Number*

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Email Address*

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Address

Street Address

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Are you the person receiving the service, or are you filling this form out for someone else?*

Are you currently or have you previously taken any medications?*

Do you currently have or have you ever been diagnosed with a mental or physical health condition?*

Please note before selecting the time and date
Your appointment is not confirmed until the payment has been received and cleared. Kindly allow at least 24 hours for the appointment to be confirmed.

After submission, the payment method details will be sent to your email.

What date and time work best for you?*

Please describe your current condition or the reason for your consultation.*

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Terms and condition:

Confidentiality
All sessions are strictly confidential. Information shared during sessions will not be disclosed to any third party without your written consent, except as required by law (e.g., risk of harm to self or others, or court orders).

Consent to Consultation
By booking this appointment, you confirm that you are voluntarily seeking mental wellness services and understand the nature of talk therapy, coaching, or counseling as explained by your therapist.

Session Duration
Standard consultation sessions are approximately [30] minutes unless otherwise agreed. Please arrive on time. Late arrivals may result in reduced session time.

Cancellation & Rescheduling Policy
We require at least 24 hours’ notice for cancellations or rescheduling. Missed appointments or late cancellations may be subject to a [full] session fee.

Fees & Payment
All payments must be made in advance. Fees are non-refundable or transferrable for missed sessions without notice or session taken.

Communication Outside of Sessions
For non-urgent matters (e.g., rescheduling), communication via email or text is acceptable. Please note that therapists may not be available for ongoing support between sessions unless agreed upon.

Crisis Policy
This service is not designed for emergency or crisis support. If you are in immediate danger or need urgent mental health assistance, please contact emergency services or your local crisis helpline.

Therapist Rights
The therapist reserves the right to decline or discontinue services if it is deemed clinically or ethically necessary.

The therapist reserves the right to reschedule sessions when necessary. In the event of a rescheduling by the therapist, the session will be moved to a mutually agreed-upon time. Please note that rescheduled sessions are non-refundable.

Legal Disclaimer
Therapy is not a substitute for medical treatment or legal advice. Clients are responsible for seeking appropriate support from other professionals as needed.

Informed Consent
By signing or submitting this form, you confirm that you have read, understood, and agreed to these terms.

Patient or Guardian Signature / Initial

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Consultation with Dr. Moiz Hussain

Consultation Disclaimer This session is a consultation only and does not include therapeutic treatment, diagnosis, or ongoing therapy services. We do not prescribe, adjust, or taper medications. Any concerns regarding medication should be directed to a licensed medical or psychiatric professional. The purpose of this consultation is to offer insights, guidance, and recommendations based on the information provided. By proceeding, you acknowledge and accept the nature and scope of this consultation.

15,000.00PKR

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Appointment Request Form